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Retailer Form

Trading Name *

Store Manager *

Store Email Address *

Store Phone Number *

Accounts Payable Contact Details

Contact Name *

Email Address *

Phone Number *

Head Office Contact

Contact Name *

Email Address *

Phone Number *

Marketing Contact Details

Contact Name *

Email Address *

Phone Number *

Sales Figures Contact Details

Contact Name *

Email Address *

Phone Number *

Store After Hours Contact Details/Emergency Contact Details

First Contact Name *

Position *

Phone Number *

Second Contact Name

Position

Phone Number

Retailer Details

Opening Hours *

Retailer Description *

Shop # *

Facebook Page Link

Instagram Account Link

Website Link

Retailer Image Assets

Upload Logo (300px x 300px) *

Drag and Drop (or) Choose Files

Upload 4 x Retailer Images to feature on website stores retailer page (300px x 300px) *

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Consent & Confirmations

Please enter the email address you'd like the email confirmation of this submission to be sent to. *

Yes, I agree with the privacy policy and terms and conditions.

Yes, I consent to be part of Centre Management communications streams (ie. What's App etc)

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Homemaker The Valley
Cnr Ann &, Wickham St,
Fortitude Valley QLD 4006
(07) 3363 5777

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